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Treatment Options
Surgical Treatments
If you choose to have surgery, your physical condition and your mental attitude will determine your body's ability to heal. It is important to approach your surgery with confidence, a positive attitude, and a thorough understanding of the anticipated outcome.
The decision to have surgery includes weighing the risks and benefits involved. You will make the final decision, so please ask questions about anything you do not understand.
If your chronic pain has not responded to conservative treatment and prevents normal lifestyle activities, your doctor may recommend surgery. The goal of surgery is to correct the problem creating the pressure on, or irritation of nerves, causing symptoms of pain and weakness.
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For the Back
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For the Neck
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For the Back
The most common procedure to correct your disc problem is a "discectomy" or "partial discectomy" in which part of the herniated disc is removed that's putting pressure on a nerve, causing pain in your back or leg. To reach the damaged disc, your surgeon forms a "window" by removing a small portion of the lamina, the bone behind the disc, in order to see the disc clearly. Bone removal may be minimal partial (laminotomy) or entirely (laminectomy). First, a thick muscle that protects the disc and nerves is moved aside, allowing the surgeon to remove the lamina and see the disc. Next, your surgeon can remove the part of the disc that is causing the pressure on the nerve. Your surgeon may recommend a "classic" discectomy, a micro-discectomy, or a percutaneous discectomy. The basic differences among these disc surgeries are the size of the incision, how your surgeon reaches your disc, and how much of the disc is removed. The "classic" discectomy and micro-discectomy require a hospital stay of a few days. Percutaneous discectomy is usually an out-patient surgery.
"Classic" Discectomy involves the removal of the disc material that is causing the pain. Your surgeon first makes an incision in the midline of your back (over the bump you feel when you run your hand over your lower spine). The incision is 2-3 inches long. Then, to see and reach the damaged disc, your surgeon removes some or all of the lamina. Next your surgeon removes the disc material that is pressing on a nerve.
Microdiscectomy is much like the "classic" discectomy, except that your surgeon uses an operating microscope or magnification loops to magnify, highlight, and see the disc. A magnified view means that the incision, located in the midline of your back, is smaller than that of a "classic" discectomy, with less damage to surrounding tissue. The incision is about an inch long.
Percutaneous Discectomy is an outpatient procedure that uses x-ray pictures and a video screen as a guide for your surgeon to reach and fix the damaged disc. The incision, made in the small of your back, is about the size of a puncture wound. Because your surgeon can see the damaged disc on a video screen, it's not necessary to remove bone to view and reach the disc. After surgery, a small bandage is placed over the incision. The incision is about ¼ inch long. To reach the disc during percutaneous discectomy, your surgeon may use a suction probe, laser probe, or forceps. After inserting the instrument into the disc, your surgeon removes the damaged disc material. Sometimes an endoscope (a tiny telescope-like instrument with a light) is inserted to view the disc area.
(ALIF) Anterior Lumbar Interbody Fusion is a surgical procedure for patients with serious, long-term low back pain that have not been helped with non-operative programs. It involves adding bone graft to an area of the spine to setup a fusion where the bone grows between two vertebrae and limits the motion at that segment. Progressive developments have been made in spinal fusion techniques since its introduction in the early 1920's. Approaches to the spine have been improved significantly as well. Transperitoneal exposures (approaching through the membrane lining the walls of the abdominal and pelvic cavities) have been replaced by Retroperitoneal exposures (approaching behind the peritoneum) - maintaining the integrity of the peritoneum and approaching the spinal column laterally. The advantage is less post-operative bowel problems for the patient. Radiographic studies; plain films, bone scan (SPECT), CT scan, MRI and discography are usually part of the evaluation process. Frequently more than one of these diagnostic studies is needed for an accurate diagnosis. ALIF may be utilized as an isolated procedure or in conjunction with posterior spinal fusion. The method with which ALIF is accomplished depends largely on the surgeon's preference and experience. Minimally invasive techniques - open or laparoscopic - require greater intraoperative attention to detail and preoperative surgical planning.
Posterior Decompressive Laminectomy / Foraminotomy. A lumbar laminectomy is a surgical procedure that is performed on the lower spine to relieve pressure on one or more nerve roots. In this operation, the surgeon reaches the lumbar spine through a small incision in the lower back. Through this opening, your surgeon will reach the area where your cauda equina and/or spinal nerve(s) are being pinched. A retractor is used to pull aside fat and muscle to expose the vertebra. A fine drill is then used to remove a section of the lamina. Next, an opening is cut in the ligamentum flavum through which the spinal canal can be reached. Once the spinal nerve root(s) and cauda quina have been exposed, pressure is relieved when your surgeon uses a fine drill to remove the source of compression - bone spurs or rough edges of the intervertebral disc. When the foramen becomes clogged with debris, nerve roots may become irritated resulting in inflammation. Your surgeon will shave open the inside of the foramen (window) to increase its size. This procedure (foraminotomy) provides ample space for the nerves and eliminates compression, allowing the inflammation and associated pain to diminish. The open windows allow the nerves exiting the spinal column to easily slip through the foramen. A laminectomy is effective to decrease pain and improve function for patients with lumbar spinal stenosis. Spinal stenosis is a condition that primarily afflicts elderly patients, and is caused by degenerative changes that result in enlargement of the facet joints. The enlarged joints then place pressure on the nerves, and this pressure may be effectively relieved with a lumbar laminectomy.
Instrumentation and Fusion Spinal instrumentation is a generic term for surgical procedures that incorporate the use of screws, rods, cages, plates, and/or cylinders. These are medically designed implants or spinal implants. Fusion simply means the addition of bone (bone graft) and may be used in conjunction with spinal implants. When fusion and implants are combined, it can provide structural support where the spine has failed. Fusion is similar concrete (bone grafts) reinforced with steel (instrumentation). When redundant vertebral motion (same repeated action) places constant pressure on surrounding nerves, pain may result. Fusion stops the movement and either eliminates or reduces the pain. With spinal instrumentation and fusion working together, the patient may be able to get up the day following surgery. Before medically designed implants were available, bone grafting (bone tissue) simply was not enough to provide immediate spinal stability. In those days, the patient was put into a plaster body cast to hold everything still so the area could fuse. Using implants, the bone actually may grow around the rods and/or other spinal implants ... similar to reinforced concrete. Fortunately patients are no longer placed in plaster casts following back surgery. Sometimes the physician will order a corset or non-rigid support designed to limit spinal motion. These brace-like supports are intended to restrict movement much like a splint. They are worn on a short-term basis. As soon as an x-ray proves fusion has occurred, the use of the brace may be discontinued. Some patients fear their spine will be stiff as a board following fusion. However, this is not true. Consider the mechanics of standing up and sitting down. Most of the motion occurs in the hip joints, not in the spine. Fusion will not prohibit the patient from bending over, but it will limit a portion of the spine's motion. The trade-off is acceptable because after fusion pain from movement may be eliminated or reduced.
Anterior/Posterior (360° Fusion) Many times a procedure in which both the front and back of the spine are fused will be recommended for a patient who has a previous failed fusion (the initial fusion did not set up), multiple level involvement, or for a patient with a high degree of spinal instability (e.g. fractures), or in the face of a deformity, such as scoliosis, spondylolisthesis, and/or in a high risk category, such as for a patient who smokes. Fusing both the front and back provides a high degree of stability for the spine and a large surface area for the bone fusion to occur. The disc will be approached as with an (ALIF) Anterior Lumbar Interbody Fusion on the front of your spine, where your surgeon will remove the disc (cushion between vertebrae) and any arthritic areas, and place a bone graft between the vertebrae where it eventually fuses to the surrounding vertebrae to stop abnormal motion. With the fusion procedure performed in the back of your spine (Posterior Instrumented Lumbar Fusion), a bone graft and instrumentation will be placed on the sides of the vertebrae where they will grow together to the vertebrae to stop abnormal motion. The bone graft may be one of two types: an autograft (bone taken from your own body usually your pelvis) or an allograft (bone from a bone bank). The "instrumentation" which may include metal rods, screws or hooks, is also used with the bone graft to further stabilize the spine. When the vertebrae have been surgically stabilized, abnormal motion is stopped and function is restored to the spinal nerves.
For the Neck
The neck is an extremely flexible part of the body, but strong enough to hold up your head, which may weigh 10 pounds or more. The seven bones in the neck (called the cervical spine) are separated by elastic, shock-absorbing discs. The spinal cord runs through a large central opening (spinal canal) formed by the vertebrae. Nerves branching from the spinal cord travel to your arms and other parts of your body through smaller openings (foramina) in the vertebrae. Neck pain may result from abnormalities in the soft tissues - the muscles, ligaments, and nerves - as well as in bones and joints of the spine.
One of the most common cervical spine problems is a damaged disc. A disc may be injured by a sudden movement (herniated), or it may wear out gradually (degenerated). A worn-out disc may become so flat that the vertebrae above and below it touch or slip back and forth. As discs wear out, abnormal bone growths (bone spurs) can form between the vertebrae and in the foramina (stenosis).
If conservative care hasn't helped your neck pain, your surgeon may recommend cervical disc surgery. During surgery, your doctor may remove all or part of the disc (discectomy) and bone spurs pressing on your nerves or spinal cord. Your cervical spine may be reached from the front (anterior) or the back (posterior) of your neck. With the anterior approach, you may also need a fusion to add stability to your neck.
Anterior Cervical Discectomy and Fusion, with and without plate (ACDF) is the procedure in which your surgeon will make a horizontal or vertical incision on one side of your neck. To reach the disc, soft tissue is moved aside. The disc irritating the nerve is then removed. Your doctor may then prepare the vertebrae for a fusion, in which the vertebrae above and below the removed disc are joined (fused). Fusion is done with a bone graft, but occasionally metal plates are added. After enlarging the space between the vertebrae, your doctor "plugs" the opening with a cylinder or wedge-shaped bone graft. In the healing process, the graft and vertebrae grow together.
Posterior Cervical Laminectomy, with and without fusion is the procedure in which your surgeon makes an incision in the middle of the back of your neck to remove the lamina (laminectomy) or the bone around the foramen (foraminotomy)to reach the damaged part of the disc. All or part of the herniated disc is removed. You may need a fusion to add stability to your neck. During fusion, your surgeon joins (fuses) the vertebrae above and below the removed disc. Fusion is done with a bone graft, but occasionally metal plates are added. As you heal, the graft will fuse to your facets decreasing motion and adding stability.
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